Historians generally now recognize the futility of searching for the “origins” or “foundations” of the welfare state in the Victorian-era poor law. Parish medical relief after 1834 (apart from being locally fragmented beneath a veneer of a nationally coherent system) was in almost all places a practical shambles and consistently more irregular and chaotic than provisions for “able-bodied” paupers. Still, the question has long been to what extent poor law reforms advanced the notion of state responsibility in medical care. Kim Price's book fits with the new historiographical consensus that sees parish medical services as one part of a very fragile mix of welfare sources utilized by poor persons in the Victorian period. Along with a number of medical and welfare historians, it argues that the perceived crisis in poor relief in the last decades of the century was in fact an outcome of systemic neglect manufactured by the increasingly ruthless application of New Poor Law principles. This conclusion is not without lessons for our own age of austerity.
This valuable book focuses on the role played by the poor law, administrators, and contracted doctors in producing ideal conditions for the widespread medical abandonment of paupers. The result was a rising wave of official charges of and investigations into individual cases of negligence. Price begins by sketching the somewhat narrow legal meaning of medical “negligence” as an issue of contract law created by the medical officer's terms of employment. Paupers were not deemed to have a direct relationship with parish doctors, and negligence thus could only be a matter of breach of duty to employer (the parish). “Negligence” provides a unifying theme, but Price's real focus is upon poor law medical officers and how their duties were made increasingly impossible by central and local pressures. The three chapters of part one establish background as to why charges of negligence against poor law doctors increased over the second half of the century. Much of this landscape will be familiar to historians of the poor law and state medicine, though Price puts significant flesh upon our skeletal understandings by effectively combing extant poor law records in the National Archives. Chapter 2 details the untenable terms of parish employment resulting from very tight competition among local practitioners, absurdly low remuneration, and stipulations for medicine to be provided out of inadequate salaries. Doctors actually underbid one another to become officials destined to be severely overworked and just as severely underpaid—a situation that helps explain the lackluster and ultimately futile attempts to organize an effectual Poor Law Medical Officers’ Association. An analysis of salaries data places these developments in context of a savage ideological attack on expenditure and an unshakable faith in free trade. In chapter 3 Price mines official inquiries into charges of neglect, mapping these against the shifting winds in poor law reform and establishing that medical negligence had always been a key register of controversy in debates over standards of care. Chapter 4 brings special attention to the Poor Law Inspectorate, showing that Inspectors’ slapdash form of damage control placed official blame for any instance of patient neglect exclusively with “scapegoated” doctors.
Part two of the book offers three substantive chapters in which Price lays out medical consequences of the so-called crusade against outdoor parish relief. In chapter 5 he presents this as a popular ideology of limited state intervention in matters addressing poverty, but he sidesteps the question of how popular the crusade actually was. Price maps charges of medical neglect and uses these as a “divining rod for identifying crusading unions” (120). The crusade took off in the 1870s–1880s and fed a rise in (paradoxically, more expensive) institutional care. It was mostly after this point that workhouses became de facto hospitals of first resort for many poor sick. As chapter 6 shows, this occurred in an environment that placed a premium on making workhouse conditions as near to repulsive as possible, and that is where Price engages with debates over whether the new investments in workhouse infirmaries (most notably in London) supported a decline in standards of care, including in pauper nursing. In a welcome departure from the mostly synoptic evidence of much of the book, this chapter provides an extended explication of the death of Edward Cooper in the Isle of Wight workhouse in 1877. This man essentially starved to death in custody, Price argues, not because of his severe disablement but because he had been “left to fend for himself” in the workhouse (147). The case epitomizes how institutional neglect was fostered under the poor law apparatus; nonetheless, all the while “the public were hoodwinked into blaming doctors for systemic faults” (148). In the final chapter Price seeks to explicitly evaluate the culpability of parish medical officers for such failures and finds that they were caught in a catch-22 regarding their very limited contracts and their very heavy actual workloads.
One drawback of Price's organization is that the significance of medical negligence comes into view late in the book. Price has a powerful argument to make about how the poor law produced a system of organized neglect. The dispassionate parsing of “negligence” within contract and administrative law in early chapters sits incongruously with the urgent and appalling consequences of these arrangements presented in later chapters. Furthermore, Price clearly follows the lead of many academic historians in deliberately avoiding the narrative aroma of scandal and melodrama, even though this is how the Victorian public itself often framed the abuses of medicine and the poor law. The stereotype of the callous and inattentive parish medic was well established by the 1860s. While Price abundantly shows why the medical neglect trope was unfair and misplaced, he has little to say about the trope's public consumption or about how the scapegoating of doctors eventually gave way to other forms of criticism. (Price hints that the environment was significantly different by the 1890s, but this is not explored in any great detail.) Given the arcaneness of poor law administration, this book will appeal almost exclusively to specialists in welfare and medical history. Medical Negligence in Victorian Britain nonetheless is a noteworthy and meticulously sourced contribution to the social history of medicine and the Victorian poor law.
